Civil Society in the Fight for Universal Health Coverage in Nigeria
Universal Health Coverage (UHC) ensures that all individuals enjoy the right to quality healthcare without incurring financial hardships. The World Health Organisation simplified the definition of UHC as a system where everyone receives the healthcare they need, when and where they need it, without facing financial difficulties. The core principles of UHC are equitable access to quality healthcare for everyone irrespective of income, social status, location or race; the provision of high-quality healthcare that is tailored to the specific needs of individuals and communities; and financial protection to cushion the possible financial hardships individuals might incur due to the cost of healthcare.
UHC was designed to make the right to health inalienable, breaking through barriers and obstacles that prevent certain individuals, especially in underserved and rural communities, from having equal healthcare opportunities and services like every other person in the world. The UHC’s above-stated goals are in line with healthcare’s position as a fundamental human right. Governments across the world, particularly democratically elected governments, are constitutionally mandated to ensure that the fundamental human rights of their citizenry are protected. Therefore, prioritizing qualitative and accessible healthcare is a core duty of the government.
In providing this qualitative and accessible healthcare, collaboration is needed between governments, healthcare providers, and civil society. This is because while the government provides the funding and enacts policies to meet UHC goals, and healthcare providers serve at the frontline of healthcare service delivery, civil society organisations must hold the government accountable to its duties by ensuring equitable distribution of resources to underserved areas, and the participation of the citizenry in healthcare policy-making processes.
State of Universal Health Coverage in Nigeria
In Nigeria, a lower middle-income country, and the most populous black nation in the world, people die due to avoidable causes that can be traced back to significant healthcare challenges. These challenges are fixable and are related to a weak healthcare system characterised by insufficient funding, inadequate infrastructure, and poor access to quality healthcare facilities, especially in rural areas with notable geographical barriers. The healthcare system in Nigeria is largely controlled by the public sector, with the tertiary and secondary level health facilities situated in urban areas, whereby the primary healthcare facilities are mostly serving the rural communities. These tiers of healthcare facilities are controlled by the federal, state and local governments, with the federal government controlling mostly the secondary and tertiary levels. Based on this arrangement, there has been a significant gap in healthcare inequalities, as people in the primary tier level may experience some difficulties in accessing sophisticated healthcare services from secondary or tertiary tier facilities. Some of these difficulties may be distance, causing patients to pay certain out-of-pocket fees which can plunge them into poverty given that most people from rural communities in Nigeria battle multidimensional poverty. Although the federal government of Nigeria provides some support to the primary and secondary tier levels of health facilities for the local government and state government facilities respectively, that support is not enough. The general budget of the federal government’s health expenditure is 6% of Nigeria’s gross domestic product representing one of the lowest in the world and cannot sufficiently contain the needs of over 200 million people.. This figure is far less than the 15% approved by the WHO.
Presently, Nigeria is undergoing a crucial transition in its healthcare system with a burden of infectious and non-communicable diseases, and a shift from donor assistance to domestic financing for healthcare. This transition is affecting its capacity to zero in on the universal health coverage demands. Nigeria faces three primary challenges in this regard:
Number one is inadequate policy implementation. This includes the inability to fully execute crucial policies such as the National Health Act or basic healthcare provision fund, which limits policy awareness, leads to low government spending on health and poor evidence generation for decision making. When there is poor data on the beneficiaries of these policies, government budgeting for them will be affected, hence individuals will miss out on opportunities that should have enhanced their ability to receive healthcare services without spending excessively from pocket.
The National Health Insurance Authority Bill signed into law on the 22nd of May 2022 with the view of providing mandatory universal health coverage to all Nigerian citizens and legal residents, is a major example of poor policy implementation. Despite its noble and lofty goals as a social contract ensuring the obligatory provision of healthcare insurance by the government, the policy’s implementation was affected by several factors. The main one is the socioeconomic effect of the COVID-19 pandemic whose effect is worsened by other factors like limited fiscal space due to macroeconomic difficulties and specific geopolitical challenges especially violence and terrorism in particular regions of the country.
Number two is limited knowledge and capacity for execution. Poor availability of data, research and the lack of technical know-how to implement health insurance programs at subnational levels, including poor data management and lack of collaboration between government agencies and designated ministries, grossly affect policy implementations. For instance, it hinders a proper understanding of the full range of the healthcare needs of Nigerians.
Number three is financial limitations. The overall healthcare system of Nigeria, which is largely controlled by the public sector, is underfunded. As stated above, only a mere 6% of the Nigerian GDP goes to this important sector. Such a low budget for the healthcare sector has multifunctional effects across every department of the healthcare service industry, reducing the quality of the healthcare services that are provided.
These challenges can be traced to governance failures particularly the social and administrative distance between the government and its rural masses. This distance is accentuated by Nigeria’s overt concentration of powers and resources at the federal and state levels to the detriment of local governments. As a result, local governments cannot fulfil their constitutional responsibility of meeting the needs of citizens within their constituencies. Healthcare lamentably features high on the list of unmet needs as evidenced by the deplorably poor condition of Nigeria’s primary healthcare system which is under their purview.
These conditions could be significantly improved if the recent Supreme Court ruling granting financial autonomy to local governments is duly complied with. The ruling ensures that Nigeria’s governance system aligns with the true tenets of federalism which should foster increased grassroots development by bringing the dividends of democracy closer to the localities and rural areas, as opposed to concentrating everything in the cities as a result of their proximity to federal and state governments. This recently ratified financial autonomy for local governments could signal good news for primary healthcare systems especially if local governments are monitored to ensure they properly utilise their allocations. The increased allocation of funds is bound to reflect positively on healthcare infrastructure and delivery if observation measures are put into place.
The Contributions of Civil Society in the Implementation of UHC in Nigeria
The role of civil society in advocating for universal health coverage in Nigeria cannot be overemphasised. This is because Civil Society Organisations (CSOs) are not-for-profit organisations formed by the people to facilitate the growth and development of the community, and to serve as mediators between the government, healthcare providers, and the community, making sure that the voices of underserved communities, minority groups and marginalised demographics are heard. In democratic settings, they can serve as supervisory agencies, ensuring that the government does its work, and holding all the stakeholders of the healthcare industry accountable for the responsibilities committed to them. Their roles involve monitoring government spending on healthcare, following up with the implementation of healthcare policies, and advocating for enhanced funding for healthcare. They also raise awareness about healthcare issues in the country, sensitising communities on their rights to healthcare access, getting them involved in healthcare governance and promoting health education in the process.
Some of the notable civil society organisations with a purview on healthcare in Nigeria include the Health Reform Foundation of Nigeria (HERFON), the Nigerian Medical Association (NMA), and the Civil Society Legislative Advocacy Centre (CISLAC). HERFON advocates for reform of Nigeria’s healthcare sector and increased funding for the healthcare industry to zero in on the global healthcare mandate. It collaborates with policymakers, healthcare providers, and communities to promote universal health coverage. The Nigerian Medical Association (NMA) is a body of healthcare professionals in Nigeria who serve as a watchdog for professional healthcare delivery. It advocates for improved working conditions for healthcare professionals, better healthcare funding to enhance the infrastructural capacity of the healthcare sector, and enhanced access to quality healthcare services for all. The Civil Society Legislative Advocacy Centre (CISLAC) investigates the operational framework of policies on healthcare to ensure it meets the demands of the populations it was designed for, then advocates for increased funding to cover lapses in the healthcare sector. This organisation collaborates with policymakers and healthcare providers to ensure the implementation of Universal Health Coverage in Nigeria.
Despite their functions and activities in Nigeria, civil society organisations face the following challenges in helping to implement UHC:
Poor funding: these organisations rely on local and international funding opportunities that are not only unpredictable but also limited. This prevents them from expressing the full extent of their responsibilities, and abilities, including the resources to sustain their activities.*
Government resistance: some government officials perceive CSOs as a threat to their functioning, hence the clamp down on CSOs’ activities and the resistance to their efforts.
Weak institutional capacity: some civil societies lack proper institutional structure and governance; hence they cannot attract certain funds and expertise needed to handle demanding activities in the populations they advocate for. They require training and capacity-building to harness their potential and sharpen their advocacy skills.
Despite these significant challenges, civil society organisations have contributed to successful interventions involving community mobilisation and partnerships with local governments to provide meaningful change in the Nigerian healthcare sector. A major example of such interventions is the Saving One Million Lives Programme for Results (SOML-PforR) campaign, which involved CSOs on the steering committee of the drive to address the main causes of morbidity and mortality among pregnant women and children under the age of five. Another is the Polio-Free Nigeria efforts, in which CSOs have significantly contributed by leveraging their extensive networks to advocate for domestic funding, raising awareness on vaccination and risk, and enabling community mobilisation through volunteering. CSOs also played a pivotal role during perhaps the most significant modern health emergency— the Covid-19 pandemic. Among other key contributions during the pandemic, CSOs were particularly instrumental in raising awareness and rebutting disinformation about the virus. They performed these roles despite challenges such as being omitted from the government’s official pandemic response architecture, the closure of civic spaces due to the quarantine, and the loss of funding.
Strategies for Effective CSO Engagement in Promoting UHC in Nigeria
Civil society organisations as non-governmental organisations cannot fully function without proper collaboration with the relevant stakeholders in the Nigerian healthcare sector. This collaboration enables them to effectively advocate for policy changes, increase awareness, and supervise government expenditure to ensure the government caters to the health demands of the country. The strategies for their engagement can be grouped into short-term, medium-term and long-term.
On the short-term front, CSOs should address the issue of weak institutional structure, by building partnerships with the stakeholders of the Nigerian healthcare sector including private-sector health clinics, community-based organisations, religious communities, and healthcare providers across the country. In addition to leveraging expertise and institutional governance, these organisations can provide more resources and networks that strengthen CSOs in doing their job. An example is the Nigerian Civil Society Coalition on Universal Health Coverage (NCH-UHC) which brings together civil society organisations and the relevant stakeholders in the health sector to promote activities towards actualising UHC in Nigeria.
Similarly, CSOs should understand that structure is important in attracting investment, sourcing funds, and engaging organisations for collaboration. Therefore, capacity building is imperative. They can achieve this by training their members on advocacy, policy analysis, research methods, and data handling and management. They can leverage the opportunities provided by organisations like the Global Health Advocacy Incubator, to provide their members with the support, training and competence needed to undertake tasks geared towards promoting UHC in Nigeria.
In line with this, CSOs should consider data-driven advocacy and research since data collection and research are critical in informed decision-making by the government and other stakeholders relative to promoting universal health coverage in Nigeria. This will also enable them to promote evidence-based policymaking through conducting surveys, analysing healthcare data, and publishing research reports to inform the public. In addition, it enables them to tackle misinformation which is one of the key contributors to poor healthcare engagement in the country.
Another short-term strategy CSOs should consider is community mobilisation because the promotion of awareness and demand for UHC cannot be completely achieved without mobilising communities that are affected. This involves organising outreach programs, town hall meetings, and social media campaigns. One of the instances of mobilisation by the CSO is the White Ribbon Alliance Nigerian (WRAN) which mobilises communities to seek healthcare services and promote awareness about maternal and child health.
Furthermore, on the medium-term front, given the number of social media users, and the global reach that can be achieved via posts and online campaigns, CSOs should leverage social media and digital platforms to promote and advocate for UHC. It can include creating online petitions, interacting with people with whom the UHC was created in Nigeria through online engagements, publishing blog posts and articles for the advancement of healthcare programs and creating awareness. Furthermore, they can also trend hashtags and join certain online trends that promote UHC.
Pertinently, engaging in advocacy and policy dialogue to influence decision-making is an effective way of ensuring the promotion of UHC. This strategy runs across the three terms. Short-term advocacy goals could be tailored towards campaigns to increase health budgetary allocations. On the medium-term and long-term front, CSOs should be more involved in advocacy towards the widespread adoption of local government autonomy. In the medium term, this advocacy will involve monitoring the utilisation of funds by local governments that are already enjoying autonomy.
In the long term, this advocacy should aim to push for local government autonomy beyond financial independence and towards political independence. Political independence in this context implies that local government administrations are granted relative autonomy and freedom to carry out their constitutional duties without interference and external influence from other tiers of government. This advocacy strategy across various terms can take several forms such as policy forums, engaging with policymakers, and advocating for policy changes to favour specific demographics. This can help foster conversations on sensitive topics that affect marginalised groups and limit their access to certain healthcare opportunities and services under the UHC.
Conclusion
Universal Health Coverage in Nigeria suffers from poor funding, and inadequate infrastructural facilities in the healthcare sector to advance access to Nigerians without financial hardship. Based on the estimates of the World Health Organisation, Nigeria spends just 6% of its GDP out of the 15% recommended by the WHO on its healthcare system. This is insufficient to cater to the needs of over 200 million Nigerians. To ensure that government spendings are checked and properly managed, civil society organisations have engaged in a series of activities including advocacy campaigns, sensitisation, and dialogue on policy frameworks to achieve UHC. However, their activities are limited by factors that can be easily fixed. The key strategy for CSOs advocating for UHC in Nigeria is to build a strong institutional capacity. This will enable them to address unnecessary government spending and the poor allocation of funds for UHC implementation. Additionally, it will enhance their ability to attract international resources, such as funding, professional training, expertise, and knowledge. These resources will help CSOs effectively manage and utilise data to achieve their goals. Going forward, CSOs should learn how to collaborate with different stakeholders of both local and international healthcare systems to advocate for Nigeria’s full implementation of UHC.
*Editor's Note: At the time Dorothy wrote this blog, USAID was still actively involved in the African funding space. While their departure adds another layer to the challenges she highlights, it underscores the importance of having these conversations—especially as we mark the International Day of Social Justice. Stay tuned for Titilayo’s upcoming blog, where she delves deeper into the USAID issue.
Dorothy Ibifuro Fakrogha is an Admin/Research Assistant at the Centre for Democracy and Development (CDD-West Africa)